Provider Demographics
NPI:1942327283
Name:GENESIS DEVELOPMENT
Entity Type:Organization
Organization Name:GENESIS DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-386-3017
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129-0438
Mailing Address - Country:US
Mailing Address - Phone:515-386-3017
Mailing Address - Fax:515-386-4642
Practice Address - Street 1:401 W MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129-1421
Practice Address - Country:US
Practice Address - Phone:515-386-3017
Practice Address - Fax:515-386-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0400617Medicaid
IA0402653Medicaid
IA7741769Medicaid
IA0741769Medicaid
IA0400620Medicaid
IA0400621Medicaid
IA2748996Medicaid
IA5741769Medicaid
IA1741769Medicaid
IA2741769Medicaid
IA4741769Medicaid
IA0400618Medicaid
IA0400619Medicaid
IA0402652Medicaid
IA3741769Medicaid
IA9741769Medicaid
IA0748996Medicaid
IA1748996Medicaid
IA6741769Medicaid
IA8741769Medicaid